What is the management of a C4-5 (cervical 4-5) facet linear nondisplaced fracture?

From the Guidelines

Management of a C4-5 facet linear nondisplaced fracture should prioritize conservative treatment with a rigid cervical collar for 6-12 weeks, as this approach allows for proper healing and alignment while minimizing the risk of neurological complications 1.

Key Considerations

• The patient should wear the collar continuously except during bathing, with follow-up imaging at 2,6, and 12 weeks to ensure proper healing and alignment.
• Pain management includes acetaminophen (500-1000mg every 6 hours) and NSAIDs like ibuprofen (400-600mg every 6-8 hours) for the first 1-2 weeks, with muscle relaxants such as cyclobenzaprine (5-10mg three times daily) for associated muscle spasms.
• Activity restrictions include avoiding heavy lifting (>10 pounds), contact sports, and activities that strain the neck.
• Physical therapy should begin after 6-8 weeks once healing is confirmed, focusing on gentle range of motion exercises and gradual strengthening.

Rationale

• Nondisplaced facet fractures typically have good healing potential without surgery when properly immobilized 1.
• The rigid collar provides stability while allowing the natural healing process to occur, preventing the fracture from displacing and potentially causing neurological complications.
• Prolonged immobilization can have significant attributable morbidity, but the risk of missing a cervical spine injury or delaying diagnosis can lead to increased rates of secondary neurological injury and permanent neurological deficits 1.
• The use of entire cervical CT scans can help detect additional injuries and reduce the risk of missing unstable injuries, with a sensitivity of 100% in some studies 1.

Monitoring and Follow-up

• Regular follow-up imaging is crucial to ensure proper healing and alignment, and to detect any potential complications or displacement of the fracture.
• The patient should be monitored for new neurological symptoms, increasing pain, or any other signs of complications, and surgical intervention should be considered if necessary.

From the Research

C4-5 Facet Linear Nondisplaced Fracture Management

• The management of C4-5 facet linear nondisplaced fractures can be approached through nonoperative means, with studies showing a high success rate for this method 2.
• A study published in 2018 found that nonoperative management was successful in 82.9% of patients with unilateral, nondisplaced cervical facet fractures, with the remaining patients developing instability requiring surgery 2.
• The use of external immobilization, such as a hard cervical collar, is a common approach for managing nondisplaced cervical facet fractures, with the goal of providing stability and promoting healing 2, 3.
• The choice of immobilization method, such as a soft collar versus a rigid collar, may not significantly impact neurological outcomes, although rigid collars may provide greater stability 4.
• Initial assessment and management of cervical spine fractures, including C4-5 facet linear nondisplaced fractures, should follow Advanced Trauma Life Support (ATLS) protocols and involve a multidisciplinary approach to optimize long-term functional outcomes and minimize serious complications 3, 5.
• Imaging, such as CT scans, is an essential component of the diagnostic workup for suspected cervical spine fractures, including C4-5 facet linear nondisplaced fractures 5.
• Geriatric patients with cervical spine fractures, including those with C4-5 facet linear nondisplaced fractures, may be at increased risk for morbidity and mortality associated with immobilization, highlighting the need for careful assessment and management in this population 6.